PANIC DISORDER

Panic Disorder
• It is characterized by anxiety, which is intermittent and unrelated to
particular circumstances (unlike phobic anxiety disorders where,
though anxiety is intermittent, it occurs only in particular situations).
• The central feature is the occurrence of panic attacks, i.e. sudden
attacks of anxiety in which physical symptoms predominate and are
accompanied by fear of a serious consequence such as a heart attack.
• The lifetime prevalence of panic disorder is 1.5 to 2%.
• It is seen 2 to 3 times more often in females.
Classification [ICD10]
• F41.0 Panic disorder
• F41.1 Generalized anxiety disorder
• F41.2 Mixed anxiety and depressive disorder
• F41.9 Other specified anxiety disorders
Etiology of Anxiety Disorders (both Panic
Disorder and Generalized Anxiety Disorder-GAD)
Genetic theory
• Anxiety disorder is most frequent among relatives of patients with
this condition.
• About 15 to 20% of the first-degree relatives of patients with anxiety
disorder exhibit anxiety disorders themselves.
• The concordance rate in monozygotic twins of patients with panic
disorder is 80%.
Biochemical factors
• Alteration in GABA levels may lead to production of clinical anxiety.
Psychodynamic theory
• According to this theory, anxiety is usually dealt with repression.
• When repression fails to function adequately, other secondary
defense mechanisms of ego come into action.
• In anxiety, repression fails to function adequately and the secondary
defense mechanisms are not activated.
• Hence, anxiety comes to the forefront.
Behavioral theory
• Anxiety is viewed as an unconditional inherent response of the
individual to a painful stimulus.
Cognitive theory
• According to this theory, anxiety is related to cognitive distottions and
negative automatic thoughts.
Clinical Features
• Shortness of breath and smothering sensations
• Heart and beat rapid and pounding
• Choking, chest discomfort or pain
• Palpitations
• Sweating, dizziness, unsteady feelings or faintness.
• Nausea or abdominal discomfort
• Depersonalization or derealization
• Numbness or tingling sensations
• Flushes or chills
• Trembling or shaking
• Fear of dying or having a heart attack
• Fear of being out of control, agoraphobia, depression.
Course
• The onset is early third decade with often a chronic course.
• It occurs recurrently every few days.
• The episode is usually sudden in onset and lasts for a few minutes.
• More than 95% of those diagnosed with agoraphobia have an
accompanying diagnosis of panic disorder.
• Up to two-thirds of those with this disorder also experience
depression or engage in substance abuse to cope with anxiety.
Diagnosis
• Tests to rule out organic or pharmacologic basis for symptoms (some
physical conditions and drug effects can mimic panic disorder).
• Serum glucose measurements to rule out hypoglycemia.
• Thyroid function tests to rule out hyperthyroidism.
• Urine and serum toxicology tests to rule out presence of psychoactive
substances such as barbiturates, caffeine and amphetamines
• Based on ICD10 criteria.
Treatment Modalities
Pharmacotherapy
• Benzodiazepines (for example, alprazolam, clonazepam).
• Antidepressants for panic disorder
• Betablockers to control severe palpitations that have not responded
to anxiolytics (for example, propranolol).
Behavioral Therapies
• Relaxation techniques to help the patient cope with a panic attack by
easing physical symptoms and directing attention elsewhere.
• Deep breathing exercises, which also reduce the risk of
hyperventilation.
• Progressive relaxation, which in involves conscious tightening and
relaxation of the skeletal muscles in a sequential fashion.
• Positive verbalization or guided imagery, in which the patient elicits
peaceful mental images or some other purposeful thought or action,
promoting feelings of relaxation, renewed hope, and a sense of being in
control of a stressful situation.
• Listening to calming music.
Cognitive Therapy
• Teaches the patient to replace negative thoughts with more realistic,
positive ways of viewing the attacks.
• Helps the patient to identify possible triggers for the panic attacks, such
as a particular thought or situation or even a slight change in heartbeat.
• Helps the patient to identify and evaluate the thoughts that precede
anxiety, and then restructures them to gain a more realistic perception.